How do you get someone to wear a mask?
The question is back on many people's minds as cases of the delta variant rise among unvaccinated and vaccinated people and pressures mount to mask up.
Despite mask mandates, social pressure and even rewards — giving gift cards to kids who wear their masks properly, for example — the country remains divided on mask-wearing. President Biden condemned anti-masking behavior at a press conference Thursday at the White House.
But some countries have been making progress in getting people to mask up. Researchers from Stanford, Yale, the Bangladeshi nonprofit GreenVoice and the research group Innovations for Poverty Action, among others, are conducting an ongoing study in 600 villages in Bangladesh to figure out the most effective behavior-changing techniques, with the goal of sharing them across the globe.
The researchers say these methods could be especially helpful in reducing COVID-19 transmission in low-income countries where the supply of vaccines is limited. While the measures may not work in every country, there may be helpful takeaways — including for countries such as the U.S., where masking has become politicized.
Mushfiq Mobarak, a professor of economics at Yale University, says the experiment was inspired by a concerning observation he made early in the pandemic. While working in his native Bangladesh in May 2020, he noticed that despite government masking mandates and fines for the unmasked, no one around him was wearing a face covering.
Mobarak was alarmed — masks are the best chance for Bangladeshis to stop the spread of the coronavirus. Bangladesh is one of the most densely populated countries in the world, making it nearly impossible to distance in public spaces. And a weak health care system means that people sick with COVID-19 may not immediately get the treatment they need, says Lawrence Gostin, professor of global health law at Georgetown University, who was not involved in the research.
So Mobarak set out on a quest to find out how to get Bangladeshis to wear masks.
Mobarak and a group of researchers teamed up with the Bangladesh Medical Research Council and the Ministry of Health and Family Welfare to design and conduct a program that would evaluate different strategies to increase mask-wearing.
They'd do this by testing it out in the real world — with 341,830 people in 600 villages, some in rural parts of Bangladesh and some just outside big cities. The experiment rolled out in waves from November to January.
The researchers randomly chose 300 villages to receive mask interventions for eight weeks. Another 300 villages received no intervention at all — they'd be the comparison group.
People who lived in the 300 intervention villages were subjected to a set of core practices during the testing period, inspired by "the best ideas in social, economics, psychology, marketing literature," Mobarak says.
The strategies essentially centered on free face coverings and reminders. Each household got three free masks, but people could also get free masks at mosques or markets. People were shown videos of notable Bangladeshis, such as national cricket star Shakib Al Hasan or Prime Minister Sheikh Hasina, discussing how and when to wear the face coverings. Local imams at Friday prayers discussed the importance of wearing masks using a script from the researchers. And program volunteers routinely reminded people to mask up at outdoor public spaces such as marketplaces several days a week.
In addition to the core interventions, the researchers wanted to test out a few more behavioral nudges.
To evaluate incentives, the researchers divided the test group into three. One set of villages could get $190 to purchase an item for the whole community if at least 75% of its adult residents were still masking up eight weeks after the start of the experiment.
Another tactic focused on text messages. Two-thirds of the group received text messages twice a week during the intervention period with reminders to mask up.
Finally, the researchers tested out style. One-third of the test group received a cloth mask in various colors, including one printed with the Bangladeshi flag, instead of a blue or green surgical mask.
After the eight-week period of interventions was over, researchers began the second phase of the experiment. They observed people going about their business in markets, mosques and other public spaces. For 10 weeks, they counted how many people in the villages were wearing masks.
Mobarak and his team were surprised by what they found. The core interventions — which included the free masks and frequent reminders — more than tripled mask use, from 13% in the comparison villages to 42% in the treatment villages.
Furthermore, people kept wearing masks after the volunteer promoters of masks left the villages. "Even after 10 weeks, after we finished everything, the mask-wearing persisted. That's what got us excited," Mobarak says.
None of the extra nudges or incentives were helpful, says Laura Kwong, assistant professor in environmental health sciences at University of California, Berkeley, who worked on the study.
The text messages weren't effective because people just got too many texts, she says. And the money reward didn't work because the goal — getting 75% of the village to wear masks — was too high.
Even the failed interventions are still good lessons, Kwong says. "The benefit of this study is that we learned a lot about what you don't need to do to make [masking] effective."
Individual color preferences for face coverings, however, did seem to make an impact. Those who got a blue surgical mask were 2.9% more likely to wear it than those who received green ones, Mobarak says. And in villages where cloth masks were distributed, people were 5.8% more likely to wear a mask if they received a violet one than a red one.
The next phase of the study will focus on measuring whether the mask interventions helped lower rates of COVID-19 in the villages, Mobarak says.
For now, the researchers have turned the best practices from their experiment into a model called NORM, short for:
The international development group BRAC and other partners are now scaling up the NORM model to more than 100 million people across Bangladesh, India, Mexico, Nepal, Pakistan and Uruguay. The program began in June.
Georgetown's Gostin says masking interventions could be tremendously helpful in these low-resource settings. "[Masks are] never going to prevent a raging epidemic, but it might flatten the curve to save the health system," he says. "You're using masking to buy precious time — until they get more vaccines."
Can NORM get more Americans to mask up, too?
"I don't think it would have the same dramatic effect in the U.S." says Jay Van Bavel, associate professor of psychology at New York University, who studies the social science of human behavior.
Face masks, along with vaccines, have been so politicized in the United States that they've become a symbol of identity, Van Bavel says. Surveys conducted early in the pandemic have shown that Democrats are more likely to wear masks than Republicans — and that behavior has stuck, he says. People continue to "refuse to wear masks on ideological grounds," he adds.
But some of the methods in the NORM model may be marginally helpful, Van Bavel says — offering free masks in convenient locations, for example. "I've often said there should be a box of free masks at the front of grocery stores, because some people just forget them or they're not at hand or they're financially strapped to keep replacing them," he says.
And role models can encourage health behaviors. Van Bavel cites a paper published in the journal PNAS in August. "They found that if [former President Donald] Trump had endorsed the vaccine [after he got vaccinated], that would've nudged more Republicans to get vaccinated. But he didn't come out and advocate. He didn't do a public video."
If all else fails, you can try to legislate behavior, Van Bavel says. For example, "universities and companies are now requiring everyone to get vaccinated" to be allowed to come to school or work. People may not like it — this week, protesters rallied against a school masking mandate in Tennessee — but "a lot of [employers and teachers] are at their wits' end."